Nursing Book Club

Small Great Things

A labor and delivery nurse faces an ethical dilemma

Bestselling author Jodi Picoult’s new novel, Small Great Things, centers on a labor and delivery nurse. That was all I needed to know before I bought the book. What nurse doesn’t wonder whether or not a writer outside the profession can really capture the details of the career she loves? Don’t we all secretly believe that we are the only ones who can truly understand what we do and why we do it?

The premise of Picoult’s tale is based on a real incident: Back in 2013, three African-American neonatal nurses at Hurley Medical Center in Flint, Mich., sued the hospital for racial discrimination, alleging that they had been ordered not to treat a white infant because his father did not want black nurses to touch his baby. The federal Equal Employment Opportunity Commission also filed discrimination charges against the hospital. (All these suits were later settled out of court.)

Picoult’s novel has a similar inciting incident: The protagonist, Ruth, is a mid-career black RN working in a small hospital in New Haven, Conn. She is told to refrain from caring for a newborn because the boy’s white supremacist family objects to her race. Within days, a perfect storm of circumstances leads to the infant being alone in Ruth’s care and crashing following a circumcision. The charge nurse and the only other RN available are called away for an emergency. The infant suffers respiratory failure and Ruth is left wondering whether to obey orders or intervene. This, then, is the crux of the novel: what Ruth does, why she does it, whom she tells and what consequences result. It’s a plot that intrigued me even as I poked holes in how it unfolds.

Credibility Check

Emergencies do happen more often than we’d like to think on neonatal units. So, the plot is believable that far. However, would any good RN really consider sitting on her hands in such a situation, no matter what she had been told? Next, Ruth’s license is suspended during the investigation of the child’s death. This development made me wonder if that’s really what happens in Connecticut. Since nurses are presumed innocent until proven guilty, are suspended nurses offered non-patient care positions pending investigation? Even RNs with substance abuse problems are usually allowed to reclaim their licenses after taking the steps prescribed by the licensing board.

The most perplexing element of the plot is the way Ruth learns that she is not to care for this particular infant: a Post-It note on the chart cover. This point raised many questions for me. Even as a graduate nurse, I knew that orders were orders — they were written by medical providers and were INSIDE the chart, not on sticky notes.

Knowledgeable readers will recognize that this plot point is “ripped from the headlines.” The nurses in the real incident that inspired this story alleged that the “no African-American nurses” restriction was communicated in a similar way. It’s reasonable to suppose that hospital officials who issued such an obviously discriminatory order would prefer to communicate it in an informal way. On the other hand, in the real world, the existence of such an order would be as messy for the hospital as for the nurse. (In the real incident, it was the nurses who sued the hospital, which later paid more than $200,000 in settlements.)

Another weakness of this novel is that Picoult uses every stereotype I could imagine to tell her tale. There’s a stalwart single mom with a truculent teenager; an attention-seeking minister; a problematic African-American prosecutor; and a white supremacist who later reveals a heart of gold. On top of all that, Ruth is friends with the wealthy white family that employs her mother as a housekeeper, allowing the heroine to proudly stand her ground when they offer her money. None of these characters is drawn with much subtlety.

In the afterword, the author speaks directly to readers, explaining that she has wanted to write a book about race relations in America for a long time. Small Great Things is a timely conversation-starter, but I’m sorry to say that I was distracted by the number of credibility-straining technical details and the contrivances that push the narrative forward to a surprise ending which wraps everything up a little too neatly for me. Picoult is a very popular American author with thousands of loyal fans, so I’m sure there are many that will love this book. (On January 30, Variety announced that Amblin Partners is making a movie version, to star Viola Davis and Julia Roberts.)

I give it a “B+” for representing what nurses are all about, but the storyline rates only a “C.”

Christine Contillo, RN, BSN, PHN, is a public health nurse who suggests joining a book club as a reason to put down trashy magazines and look smart on the subway.